EXECUTIVE SUMMARY

—  Providing community pharmacists with appropriate role-based read and write access to both detailed and summary care records has the potential to greatly improve patient safety, support the development of new services for patients, improve interdisciplinary working and increase the quality and continuity of care provided to patients.

—  To maximise patient safety, community pharmacists must have access to a pre-determined core data-set, for example the medication profile, active clinical conditions, allergies and previous adverse reactions. It would be beneficial for patients, the NHS and pharmacists if supplementary information, such as access to laboratory test results, is also available to pharmacists to use where appropriate and with patient consent, to support a particular role they are undertaking, for example, the provision of an anticoagulation monitoring service.

—  All community pharmacies have robust systems in place for handling patient confidential information and are subject to a wide range of legal, ethical and professional requirements. We welcome the proposed additional safeguards to protect patient confidentiality including role-based access controls and the ability for patients to choose to dissent from their information being shared.

—  We believe that community pharmacists should be involved at an early stage in the implementation of the NHS Care Records Service to study the benefits and challenges that arise in joining-up care and to provide learning to support the wider roll-out of the Service to other professionals and organisations within the NHS.

1.  INTRODUCTION

  1.1  Since the first announcement of the development of the NHS Care Records Service, pharmacists and their representative bodies have been calling for community pharmacists to be provided with appropriate role-based access to patients' Care Records.

  1.2  Providing community pharmacists with appropriate read and write access to both the detailed and summary care records has the potential to greatly improve patient safety, support the development of new services for patients, improve interdisciplinary working and increase the quality and continuity of care provided to patients.

  1.3  To maximise patient safety, we believe that community pharmacists must have access to a pre-determined core data-set, for example the medication profile, active clinical conditions, allergies and previous adverse reactions. This should be agreed in full consultation with the profession. It would be beneficial for patients, the NHS and pharmacists if supplementary information, such as access to laboratory test results, is also available to pharmacists to use, with patient consent, to support a particular role they are undertaking, for example, the provision of an anticoagulation monitoring service for the secondary prevention of stroke.

  1.4  More than one third of pharmacies in England are already able to operate the Electronic Prescription Service and we anticipate that the overwhelming majority of pharmacies will be connected to the NHS network by the end of 2007. This will provide the basic infrastructure for pharmacy connectivity to other national functionality, as it becomes available, including the NHS Care Records Service.

  1.5  In the Department of Health publication "A Vision for Pharmacy in the New NHS", (2003) the Government signalled that it would consult on the elements of patient information that community pharmacists may need to deliver appropriate healthcare services as part of the NHS pharmacy contract. This was reiterated in the 2006 Department of Health Annual Report. It is of great concern that this consultation has not taken place and consequently the uncertainty over when community pharmacists will be granted appropriate role-based access continues.

  1.6  It is unfortunate that community pharmacies have not been invited to participate in the pilot of the Summary Care Record at this key learning stage. The information that will be shared during the initial implementation will be limited to prescription information which pharmacies currently have access to, as well as information on adverse and allergic reactions to medication. This information is unlikely to be considered sensitive by the public and could greatly improve the safety of the provision of medicines to patients.

  1.7  To study the benefits and challenges that arise in joining-up care and to provide learning to support the wider roll-out of the Service to other professionals and organisations within the NHS, we believe that community pharmacists should be involved at an early stage in the implementation of the Service.

  1.8  In this paper, we outline the key benefits to patients, pharmacists and other health professionals, of community pharmacists being provided appropriate role-based access to the NHS Care Records Service. We also detail the structures currently in place to safeguard confidential patient information available to pharmacists.

2.  IMPROVING PATIENT SAFETY

  2.1  Appropriate access to the patient's summary records is necessary for many reasons. In a recent observational study,[23] 6.5% of admissions to the medical admissions unit in a teaching hospital in Nottingham were judged to be drug related with 67% of these judged to be preventable. Providing community pharmacists with access to a patient's full medication profile and information on current clinical conditions improves the safety of prescribing, for example, by allowing pharmacists to check that newly prescribed medication is not contraindicated by a coexisting disease or by ensuring that medication does not interact.

  2.2  Some medicines, such as tricyclic antidepressants, can be used in different ways to treat different conditions. A pharmacist would only be able to confirm the medication is appropriate and the dose adequate if the clinical condition being treated is known. Such information is currently available only by asking the patient who may not be able to accurately provide the necessary information or by contacting the prescriber directly which is a time-consuming and disruptive operation for both parties.

    2.3  It is important, for patient safety reasons for pharmacists to have access to information on allergies and previous adverse reactions, so that a check on the suitability of the prescribed product can be carried out at the point of dispensing. The pharmacist's detailed knowledge of side effects and potential interactions is relied on by many GPs.

  2.4  Providing community pharmacists with a baseline data-set which includes the full medication record, active clinical conditions, allergies and adverse reactions would support pharmacists in helping the Government meet its target of reducing by 40%[24] the number of serious errors in the use of prescribed drugs and help reduce the human and financial cost of prescribing errors.

3.  SUPPORTING THE DEVELOPMENT OF NEW SERVICES TO PATIENTS

  3.1  Community pharmacy is changing. In April 2005, the community pharmacy profession entered into a new contractual framework with the Government for the provision of pharmaceutical services. The framework allows pharmacies to play a more central role in patient care, with more scope for making clinical interventions and better integration of pharmacists within the primary health care team. As part of the new arrangements, community pharmacists undertake Medicines Use Reviews, conduct public health campaigns and advise patients on self care and the treatment of minor ailments. Many pharmacists are also involved in providing other locally commissioned services to meet the needs of patients in their locality, for example diagnostic testing, substance misuse services and services to care homes.

  3.2  In addition to the basic dataset for community pharmacists, required for the above reasons, pharmacists should also be provided with additional role based read and write access to specific types of information required to support that role. For example, supplementary and independent prescribing can only be effectively carried out in the community pharmacy setting with electronic access to appropriate patient information such as laboratory results and patient care plans.

  3.3  The development of Practitioners with a Special Interest was proposed by the NHS plan to improve access and convenience. In September 2006, the Department of Health published a framework[25] which acknowledged that "Pharmacists with a Special Interest" can contribute to a broad range of service objectives including: improving patient access, reducing waiting times, increasing capacity in primary care, reducing demand on secondary care and delivering value for money. The success of this programme is dependent on community pharmacists having appropriate role based access to care records.

  3.4  One example of a service provided by a small number of pharmacies is an anticoagulant monitoring clinic. Patients receiving warfarin can attend a community pharmacy for their regular blood test and dosage adjustment. This offers convenience to patients as community pharmacies are more easily accessible and have longer opening hours than secondary care clinics. This service could be more effective if pharmacists had appropriate read and write access to appropriate information about the patients they were monitoring. For example, access to previous test results and the ability to record electronically results they obtain, to allow other health professionals involved in the care of the patient to access this information.

  3.5  Access to care records would also support the role of pharmacists in providing urgent care. Pharmacy opening hours are much longer than those of GP surgeries—with routine evening and weekend opening—and full integration of pharmacies within the provision of urgent care will relieve the pressure on A+E departments and out-of-hours providers.

4.  IMPROVING THE LEVEL AND CONTINUITY OF CARE OFFERED TO PATIENTS

  4.1  Patients sometimes forget to ask their doctor questions or misunderstand the information they are given during a consultation. If pharmacists have access to records they can reinforce important health messages and correct misunderstandings—this realises the benefits of an integrated health care system, the raison d'etre of Connecting for Health.

  4.2  Pharmacists, like other service providers, must make reasonable adjustments to their service under the Disability Discrimination Act 1995, so that people with disabilities are able to access the service. Healthcare professionals, including community pharmacists, who identify patients whom they believe require support could, with patient consent, make an appropriate entry on the NHS Care Record so that other healthcare professionals are aware of the nature of the disability, and can make adjustments to the services they provide.

5.  IMPROVING INTERDISCIPLINARY WORKING IN PRIMARY CARE

  5.1  Pharmacists based in hospitals and GP surgeries have demonstrated the value that they bring to clinical teams when they have access to clinical information about patients. However, the value of community pharmacists has, to date, not been fully utilised, as they have access only to clinical information gathered from the prescription form or through discussion with the patient. Providing community pharmacists with appropriate role-based access to patient information would enable pharmacists to work more closely and efficiently with the other members of the primary healthcare team and improve the level of pharmaceutical care provided.

  5.2  Under the new pharmacy contractual framework pharmacies are required to maintain patient medication records which include details of drugs supplied to patients and advice given where the information is clinically significant. At present, other health professionals, including other community pharmacists, are unable to access and therefore cannot benefit from these records.

  5.3  As patients have the freedom to use any pharmacy this means that community pharmacists will generally not have a comprehensive medication history for each patient. By joining up the information held in pharmacy records through the NHS Care Records Service, pharmacies will be able to provide improved continuity and quality of care.

  5.4  The NHS Plan[26] committed the Government to making a wider range of medicines available over the counter. In recent years, products such as the cholesterol lowering drug, simvastatin; the antibiotic used in the treatment of conjunctivitis, chloramphenicol, and omeprazole which is used in the treatment of gastro-oesophageal reflux disease have been reclassified to allow sale through pharmacies without prescription. This facilitates patient access to medicines, reduced health inequalities and supports self-care, which was highlighted in the NHS Plan as one of the key building blocks for a patient-centred health service. Providing pharmacists with appropriate write-access to the Care Records Service will ensure that the patient's general practitioner can access clinically significant information when products have been provided to patients over the counter, ensuring these products are considered at the point of prescribing.

  5.5  Looking to the future, products such as oral contraceptives[27]may be available for sale without prescription through pharmacies. Access to relevant information about the patient would improve patient safety and help ensure joined up care.

  5.6 Securely sharing information amongst appropriate health professionals would also help improve the efficiency of some existing services. For example, the NHS Medicines Use Review service could be developed to the benefit of patients both through allowing pharmacists access to appropriate information about the patient and allowing a summary of the review to be made available electronically to other health professionals involved in the care of the patient.

  5.7  Under the repeat dispensing service, patients with stable long term conditions can collect their medicine from a pharmacy at regular intervals for up to a year without the need to return for repeat prescriptions from their prescriber. When dispensing medication, the pharmacist has a duty to check if the patient's circumstances have changed. Appropriate read access to the patient's record would support pharmacists in carrying out this check and appropriate write access for clinically significant interventions would support the continued care by the patient's GP.

  5.8  There are also instances where patients choose not to collect medicines prescribed for them. Allowing pharmacists to write to the record would highlight these instances and improve the medication record by logging medicines prescribed and received rather than simply prescribed.

6.  IMPROVING COMMUNICATION AT THE PRIMARY AND SECONDARY CARE INTERFACE

  6.1  Appropriate role based access to the NHS Care Records Service could support the seamless transfer of care between primary and secondary care.

  6.2  There are risks[28] inherent in the discharge of patients from secondary care and in the general transfer of care. Research has demonstrated that discharge medication summaries provided to the patient, GP and the patient's nominated community pharmacist help reduce re-admissions[29][30].

  6.3  Providing community pharmacists with relevant role-based access to patient information will greatly improve patient safety at the primary and secondary care interface with the potential for pharmacists to have up-to-date information and the medication prescribed to patients. If a patient's medication therapy has been changed in hospital, it can result in patient misunderstandings or problems with duplicated medicines which community pharmacists can help resolve if they have access to appropriate information.

7.  HEALTH AND SAFETY OF PATIENTS AND STAFF

  7.1  The Government has indicated[31] that it is serious about tackling violence and the threat of violence against community pharmacists and many positive steps have been taken to tackle this problem.

  7.2  It is proposed that a "violent warning marker" may be included on the NHS Care Records Service. At present some trusts operate paper based systems to alert staff about patients who have previously assaulted NHS staff and continue to pose a potential risk. This information necessary for the protection of pharmacists is currently not accessible. We believe that appropriate role-based access should be available, particularly if the pharmacist is undertaking a service that involves visiting the patient in their home.

8.  SUPPORT FOR COMMUNITY PHARMACY ACCESS

  8.1  It is also worth noting that it is not just the profession that believes that access to the NHS CRS is necessary for the full potential of pharmacy to be realised. In their recent written submission to the All Party Pharmacy Group inquiry into the future of pharmacy, Which? stated: "Consumers want and expect continuity of care and all healthcare professionals (including pharmacists) involved in their care to have access to their medical record. Without this, how can care be patient centred?"

9.  CONFIDENTIALITY

  9.1  We are aware that as community pharmacies are readily accessible to the public, pharmacy must be able to demonstrate that confidential information will be stored securely. All community pharmacies already have robust systems in place for handling patient confidential information and are subject to a wide range of legal, ethical and professional requirements.

  9.2  Pharmacy contractors are required to comply with the legal obligations of the Data Protection Act 1998, Human Rights Act 1998 and the common law duty of confidence and under the NHS community pharmacy contract, pharmacy contractors and their employees must also conform with the NHS code of practice on confidentiality. The clinical governance framework assures compliance by including polices for ensuring staff are appropriately trained and that all staff contracts include clauses on patient confidentiality.

  9.3  Pharmacists are also bound by the Royal Pharmaceutical Society of Great Britain's (RPSGB) professional "Code of Ethics and Standards" and can be held accountable for breaches. Disciplinary action that can be taken may include the pharmacist being removed from the professional register and therefore being prevented form working as a pharmacist.

  9.4  Pharmacists and their staff have worked within these regulatory frameworks for many years. However we welcome the additional safeguards that are being introduced into the NHS Care Records Service to safeguard information. This includes the use of smart cards to control access with PCT Registration Authorities providing external control on the granting of individuals' access rights, legitimate relationships, sealed envelopes and the ability for patients to choose to dissent from their information being shared. We believe that PCTs should be supported by national guidelines to ensure consistency in permitting additional access to Connecting for Health.

Lindsay McClure

On behalf of the Association of Independent Multiple Pharmacies, the Company Chemists' Association, the National Pharmacy Association and the Pharmaceutical Services Negotiating Committee

15 March 2007

24   Aim first set out in the Chief Medical Officer's Report, An Organisation with a Memory, Department of Health, 2000. Back

25   Implementing care closer to home-providing convenient quality care for patients: A national framework for Pharmacists with Special Interests; Department of Health. 2006. Back

26   The NHS Plan: A Plan for Investment A Plan for Reform; Department of Health; 2000. Back

27   Pharmaceutical Journal; Vol 278; No 7438; p 153. Back

28   Moving patients medicines safely: Guidance on Discharge and Transfer Planning; RPSGB, GHP, PSNC and PCPA Joint Publication; 2005. Back

29   Al-Rashed S, Wright D, Roebuck N, Sunter W, Chrystyn H. Inpatient pharmaceutical inputs to facilitate seamless care. Pharm J 2000; 265(7114): R60. Back

30   Brookes K, Scott MG, McConnell JB. The benefits of a hospital based community services liaison pharmacist. Pharm World Sci 2000; 22(2): 33-38. Back

31   The Pharmaceutical Journal; Vol 274 No 7339 p 261. Back